Life, Longevity and the Elderly– Hospital Versus Hospice

Medical advancements have given us longevity of lifespan. With each succeeding generation the lifespan of the human race has been increasing. At the same time, the technological advancements that have given rise to better healthcare have also created various lifestyle diseases. As the time spent in ‘old age’ increases, the challenges for senior citizens in the modern urban world get complicated. At some age after mid-sixties or early seventies, most people’s functionality heavily reduces with limited mobility, ailments in some organ-functions or reduced efficiency of metabolic functions. The dilemma for these individuals and their families is this– whether to increasingly go for the medical treatments only targeted at prolonging life by a few months to a year or to let the body naturally deteriorate and not seek any medical help for the same in twilight years. This dilemma is encapsulated in the phrase “hospital vs hospice”. Hospices refer to homes for the terminally ill which do not give medical treatment but only aide living. Hospice is a very common alternative in countries like the United States, but in India the model hasn’t picked up and is often confused with an “old age home” as prevalent in India. Author and surgeon Atul Gawande, in his book Being Mortal discusses the idea of how we can make choices when we reach age related frailty and the idea of approaching death.

Doctors and medical health professionals are largely responsible for the way a patient spends his/her waning years. The strategy that doctors should be adopting with patients who have terminal diseases should not be to simply prescribe surgery or treatment but to patiently explain to the patient their condition, its risks, life expectancy, median recovery from treatment and then let the patient take his/her own decision. This is Gawande’s stand, whose own father (also a surgeon) had a tumor in his spinal cord and the removal surgery for which would have been very risky. His father kept living with the tumor waiting for the time when it aggravated so much when he could rationalize to himself taking the risk for getting a surgery which could leave him with even more debility.

According to Atul Gawande, who is also a writer for the New Yorker, disease and organ failure is a part of life and as natural in one’s twilight years as health and wellness is in youth. Coming from a surgeon and medical professional himself, I found his thoughts very well-reasoned along with descriptive cases of choices he had seen his patients make in his medical career. The body is like a machine, after years of functioning it is bound to suffer wear and tear. Clinging on to life dearly is a choice. But slowly naturalizing that death is to come to everyone day in one way or the other is also important to internalize.

Today, in layman lingo, we only look at cardiac arrest as “natural death” in old age and all other kinds of organ failures or terminal disease induced deaths as “unnatural deaths”. I think all organs are bound to be compromised one day after lending us good use our whole life. Whether it is the heart that runs out first, the liver that fails, the kidneys that stop functioning properly or lungs that get infested with tumor, they are all natural in my eyes just as natural as the body itself is. The only difference that might be is that in today’s age organ failures or infestations can be detected months before actual collapse which usually is not in the case of cardiac arrest wherein a person dies “naturally”. That is when patients and their families have to take the decision as to whether they want to undergo tedious, painful and expensive medical treatment that would only be prolonging one’s lifespan by a few months. Does one want to die “fighting” the disease in a hospital? Or die a little earlier accepting it as part of oneself and one’s body? There is no clear answer and neither decision is right in every situation.

Gawande, despite his own stance towards palliative rather than medical treatments (there is clear difference between the two), offers a comprehensive critique of euthanasia in his book. He cites the example of Netherlands which has an ‘end of life policy’. In his opinion, the debate surrounding euthanasia has two sides– the “mistake of prolonging suffering” or the “mistake of shortening valued life”.  Gawande’s assessment is, that in the case of Dutch people, easy access to assisted suicide has had people ideologically privilege the idea of a “good death” over “a good life till the very end”. Many people opt for euthanasia even without trying to get better. The Netherlands has also been slow to develop palliative care.

The idea behind this article’s discussion of Hospital versus Hospice in old age is not to recommend one over the other. It is rather a step towards starting a healthy discussion about our own mortality so that our bodily aging doesn’t take us by surprise. As millennials brought up in a world full of private hospitals, we have to be realistic about the limits of medicine. If we pay for medical services at a hospital the body may or may not respond to the treatment. There may or may not be a sure shot cure to one’s ailment. The doctor may or may not be able find that silver lining of life in terminal diseases like cancer which forms the extreme anomaly of the normal probability curve. Yes, there is nothing wrong in hoping for that 10% chance of survival in terminal diseases, but this hope should not be at the cost of ignoring the statistically more probable outcome.

Such a discussion is relevant in India in light of the attacks on doctors in Bengal in the NRS medical college by the loved ones of a patient who passed away. Yes, private hospitals need to do more to increase trust and prevent malpractices like prescribing unnecessary tests. But at the same time we as humans need to embrace the inexorability of our life cycle.

When it comes to assisted living palliative care or hospices, they need to be modeled after the requirements of the people who will be staying there. Children of terminally ill aged patients often look for the criteria of cleanliness and safety when looking for an assisted living or nursing facility. But it is to be realized that most old people in the last few years of their life don’t simply want security, they want a meaningful life. Studies quoted in Being Mortal show that keeping dogs and cats, having interactive sessions with young children or splitting up floors into smaller units that resemble a home affects old people much more positively. The idea is to let the aged person keep shaping the story of his/her own life.

In the jump from the 20th to 21st century, because of the technological leaps, the older generation has faced a generation gap which I would evaluate as more stark than in the previous decades. With the coming of outsourcing functions to artificial intelligence, their knowledge has been deemed as redundant by millennial institutions. In the family also, despite having money, sociological studies prove that there is a decline in the status and authority of senior citizens living in their own houses. Being overwhelmed by new technology or new methods of doing things, many senior citizens have stopped applying their volition even when it comes to decision making about their own affairs.

In India especially, being a collectivist culture we see more and more children taking big decisions of buying and selling their parents’ property and also now making decisions with regard to treatments they should undergo. My own grandmother who is nearing eighty, has gotten it written in her will that she never wishes to be hospitalized in the case of organ failure, and would want her wishes to be respected. Children in their youth often lack reflexivity and are often in such a plea to prolong their ailing parents’ life even by a few months that they forget to think what their parents would want for themselves. This is especially true for dementia, Alzheimer’s or brain hemorrhage patients who are no longer able to voice their opinions at old age. These conversations regarding mortality and end of life wishes should be deemed normal within the family and should take place between parents and children while the parents are still functional and then their wishes should be reflected along with a realistic idea of what medicine can do in their particular case.

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